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02/28/2002 09: 11 - 2094683433 FIFTH FLLLJf'. <br /> WE= PERMIT APPLICATION FL-TRM SITE <br /> FILE !� MITIGATION <br /> SAN JOAQUIN COUNTY UNIT IV <br /> ENVIRONMENTAL. HEALTH DEPARTMENT (EHD n <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202���- <br /> (209) 468-3449 ��-l. <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Ir!TIR 0 ? �2 <br /> App i:alion is hereby Trade to San Jozquir,County for a permlt to COnWjct anchor In 1:311 the work described. This appiici[ion Is m.3de ii compliance wit-i San <br /> Joa uln Coun 'Oevelo ment TIt!e,Chapter 9.1115.3 and the Slandards of Sar Joaquin Count Environmental Haaith_- artmem. 2 <br /> I 'Y P P y .p Asseblor's <br /> 'JVE-L Location _Cross Streetm77Jfi —City Zip5/Jr;30F'oroet#_ _✓l( - 2 YG Z 2 <br /> rR( PERTY OwnerC-6 I�STu G 77 d /�N Address tr 6 6."X Z ISTLS i 3e Pt one# y0r <br /> C•S CvnVactoro dress I`/C0 Spc ' / �`�LG Lic# Ph>ne�°�.3 y�7 <br /> . .5d'�S/ _City ?.GtJl9 Pl fl / <br /> Gor 3ultant?Sub Contractor c+ City 'lG>>✓Li Phones <br /> GIS:,00rtllnates X (c3� 3 (r' Y "V/ F-9 `� �� Township 7-1. J Range_ R (P ZF ._Sect:on <br /> WO W TO BE PERFORMED: <br /> 7NI W WELLI BORING(CPT - PR08E YDROPUNCH,HAND-AUGER.OTHER-) Q DESTRVCTICN(&,00se tl.9 below) <br /> Q SOIL EORING# Q OVER-F59PE <br /> d WELL# 0 PRESSL RE ORO-JT <br /> 'O(I er: ___ Grout Specifics:ions: <br /> COI 4MENTS: <br /> iYP c OF YELINSTAL <br /> LATION TYPE CONSTRUCTION SPECIFICATIONS i <br /> }FJITORING Q HOLLOV, ST:M DLA.OF BOREHOLE /��S/� TIPI E CASINGS?Q YES 040 WELL CASINO DIA, <br /> a E)TRACTION 0 AIR HAMMEWDRIVEN CASING THICKNESS TYPE OF CASING: Q STEEL D PVC 0 OTHFf.1 <br /> Q W POR 0 MUD ROTARY DEPTH OF GROUT SEAL '' 3 / '-REM)E TYPE TO BE USED: C AUGERS Q HOSE <br /> p AI t SPARGE PUSH POINT GROUT SEAL PUMPED: AYes p No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> )KS(iL BORING 0 HAND AUGER GROUT SPECIFICATIONS: — <br /> }O-HER: 0 OTHER— APPROX.e0RING DEPT-I 30, -(2-7- a BOLTED TRAFFIC BOX or 0 STOVE D FIE <br /> C p CONDUCTOR CASING PROPOS=D?�U tit YES,list speaflcations <br /> •CO ANIENTS: Lt 5—U V R V o l <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS. <br /> CALL THE UNIT IV INSPECTOR 48 WORKING HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br /> he-eby certify that I have prepared this application and that the work will be done in a, cordance with San Joaquin <br /> got my Or 1 ncps, I and Regulations,and all applicable California State Laws. <br /> iign-d x 1 Title/Company <br /> �rintpl-y-Al ti , CLQ W Iti/i/P vl Date <br /> nFPARTMENT LIEF ONLY <br /> 31TI:MAP IN UNIT IV FILE, ADDRESS/:_ /7' (�"s— M-" f' <br /> ye <br /> � _ <br /> NO kK PLAN DATED: z o-z <br /> 'Ppli;anon Accepted By -- Date lzwed. Area <br /> rou Inspection 3y �� r a.•^. Date 3 I Zf=inai Inspection By Date- <br /> IL <br /> ate <br /> `est JCtion In3dEction By Date <br /> ,Ctr!VENTS I CONUITIONS: — <br /> AC)CUtvTING ONLY: A09 <br /> PE :ODES FEE INFO AMOUNT REMITTED CHECK a RECD BY I DATE PERMIT/SERVICE REQUEST a' INVOICE <br /> -5 7_, WCy-WAIVER_ C-57 Letter of Authocization tc,Sign permit, Entrenchment doc_, 1/25/c2 <br />